Clinical Cardiovascular Research

Abstract

Introduction: A 2-D Echocardiographic manifestations of pericardial disease that are not mutually exclusive were pericardial effusion or pericardial thickening. A significant number of pericardial disease cases however are without this classical features.

Methodology: In a retrospective review of pericardial echocardiography in a teaching Hospital compare the two pericardial disease syndromes. Comparism in terms of cor-morbidity and cardiac functions were carried out. Both subjective and objective assessment of echo parameters were considered for analysis.

Results: A 1414retrospective records were reviewed and 169 (10%) were seen to have either pericardial effusion 91 (5.6%), thickening 78 (4.8%) or both 6 (0.3%). There was a slight female dominance and lower mean age compared to those without echo pericardial disease findings. Pericardial effusive subjectively were seen to be associated with more cor-morbidities and complications and objectively had echo parameters indicating poor cardiac functional state. Aorta, left atrium, left ventricular internal diameter in diastole and E/A ratio were statistically different.

Conclusions: Routine echocardiography assessing pericardial diseases was observer dependent and pericardial effusion had a less favourable outcome than thickened pericardium.

Introduction

The pericardium is a structure surrounding and protecting the heart [1]. It’s composed of two layers separated by a small fluid (15 – 10mls). It confines the four chambers of the heart thereby limiting the total volume of the heart so when one chamber gets enlargement It affects the size of another chamber [2]. This is the pathophysiology bases of developing pulsus paradoxus in cardiac tamponade and constrictive pericarditis [2,4].

Pericardium can be diseased by a variety of diseases processes presenting in various forms. Both layers are usually affected in the infectious and inflammatory processes [3,4]. Acute pericarditis, pericardial effusion, constrictive pericarditis, effusive-constrictive pericarditis and calcified pericarditis are the clinical syndromes of pericardial disease [4,5]. 

On echocardiography acute pericarditis may not be detected but generally acute inflammatory process results in pain and fluid accumulation while chronic inflammation result in fibrous stranding and stiffening of the pericardium [5]. When there is cumulation of excessive fluid in the pericardial cavity, heart function could be impaired and when cumulation of fluid is rapid symptom are usually severe compared to slow fluid accumulation [5,6]. The diagnosis of tuberculosis is likely when strands are visualized in the fluid [6]. In the developed world malignancy is a significant cause of effusive pericarditis while in developing world tuberculosis stands high as a significant cause [5,6]. Thickening of the pericardium results from fibrosis, calcification or abnormal tissue deposits [5,6,7]. Both restrictive and constrictive echocardiographic pattern of heart dysfunction could be seen. Incidentally pericardium is not essential for life and one modality of treating constrictive heart failure is by stripping off the pericardium [1,7].

Methodology

In a retrospective echocardiographic review, pericardial diseases categorized as pericardial effusion, thickening or both were studied.  The two dominant manifestations of the pericardium were compared at the Jos University Teaching Hospital over a period. The parameters considered during the comparism were not different from those routinely used in assessing heart function. Of the most frequently general documented parameters, pericardial effusion, thickening and contractility were subjectively noted considering that there were different sonographers records using different ultrasound machines. The objective parameters were further compared. linear aortic diameter, left atrium, left ventricular internal diameter in diastole. E/A ratio and deceleration time were the objective parameters used. Data were presented in form of tables, carts and graphs. Categorical variables were stated in proportions while continues values were presented as mean and standard deviations. Two-sample unpaired t-test from online meta-calculator was used to compare the two groups. Level of significance is 95%.

Results

Of the 1614 reviewed record, 169 (10.4%) were recorded as having a form of pericardial disease. 91 were recorded as having effusion, 78 recorded as having thickened pericardium and 6 were recorded as having both effusion and pericardial thickening.  The mean age of pericardial age group was in the forties while those of normal pericardium was in the early fifties. There was a slight female dominance in the population reviewed.

Fig 1 proportions of pericardial disease

Fig 2. proportions of echo diagnosis seen with pericardial disease

Keys: sys – systolic, dia – diastolic, dys – dysfunction, conc- concentric hypertrophy, p.htn- pulmonary hypertension, dcm- dilated cardiomyopathy, thro. risk- thrombogenic risk, nil -none.

Fig 3. contractility’s seen in pericardial disease

Table 1. objective parameters retrieved in pericardial disease

Table 2. t-test between pericardial effusion and thickened

Discussion

Acute pericarditis in one or other of its pathological types has complicated a large number of diseases in autopsy results, and every grade has been noted from a mild fibrous pericarditis which has often escaped recognition both symptom-wise and on echocardiography.  The frankly suppurative form which is often the proximate cause of death are often pick by echo [3,4]. A frequency of 10% echo-based review agreed with the statement above.

Pericardial effusion in the study was notice to be associated with cardiac disfunctions both systolic and diastolic. This was probably connected to the more frequent association with cardiomyopathy and other heart diseases. Dilated cardiomyopathy is an end stage of diseases like RHD, peripartum cardiomyopathy, EMF, hypertensive heart disease, ischemic heart disease are common cause of heart failure in this environment [8,9]. High thrombogenic risk and pulmonary hypertension [10] are complications of various advanced heart diseases were also observed to be associated more with effusive pericardial disease.

Pericardial thickening on the other hand had fairly good contractility11. The pathology in this form was due to impaired relaxation of the ventricle either by restriction or constriction of the left ventricle [10,12,13]. The frequencies of the two pathologic processes were not determined and would be considered for another discussions. Left ventricular contractility was observed to be mostly uniform in the thickened pericardial disease while effusive pericarditis had abnormal contractility (dyskinesia or akinesia).

The objective linear measurements [14] of left atrium, left ventricular diameter were significantly deranged in effusive form of pericarditis. Ejection fraction and E/A ratio were significantly different in the two groups of patients being more detrimental in effusive pericarditis. The six patients that had both pericardial thickening and effusion were worse hit. Age was contributory [15] as the group were more elderly with poorer cardiac functions. All patients in the group had abnormal left ventricular contractility.

Although objective way of assessing full cardiac functions were not fully interrogated, observed findings were equally convincing. Other limitations in the study was the fact that many sonographers were giving objective result over a period of time using different machines. 

Conclusion

The result of the study strongly suggest that pericardial diseases with effusion are associated with more derange cardiac function and having both is even worse unlike the thickened pathology types.

References

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